The Long and Short of Therapeutic Relationships

For the last seven years, I have had the privileged opportunity to build solid therapeutic relationships with patients over the long term. Despite the frustrations and stressors therein, having the time and space to truly get to know patients over such a span of years has many benefits, both for the patient and for me, the provider of care. Long-term therapeutic relationships allow for trust to be built in such a way that I have been able to become, as it were, a part of people's lives.

Making periodic home visits to a considerable number of my patients has also engendered a considerable sense of intimacy and shared experience. Getting to know spouses, children, grandchildren and others during my visits, the web of human contact is strengthened and enlarged. Becoming somewhat of a fixture in someone's home---albeit a fixture who appears and disappears at will---creates a dynamic that simply cannot be equaled during any number of office visits. In terms of getting to know a patient and their life, there is nothing like sitting in their living room and directly experiencing their world by smelling the food cooking on the stove, seeing the room where they sleep, and getting a visceral sense of what this family's lifestyle is truly like. In my opinion, doctors should make house-calls to each of their patients at least once, if only to get a sense of how that person lives, information which is therapeutically priceless.

For myself personally, I have given my all to many of the relationships that I have nurtured with my patients over the years. Over time, that investment has paid dividends which cannot be measured, and I know that my presence has been beneficial to many. Now, as I prepare to take my leave, I can see the repercussions which the severing of those ties can have. For myself, I must process the guilt of leaving, of "abandoning" my patients (as several have described it to me as they react to the news of my departure). For them, they must accept my departure from their lives, and be receptive to a new provider and a new relationship which will have different dynamics and a entirely different feeling. For some, hopefully, that relationship will be equally or even more fulfilling for them. For others, things will just never be the same. But I remind myself that the only constant in the universe is change, and we are all experiencing that constant in this moment, whether we like it or not.

As I move into a new paradigm of work as a nurse, I will embrace the opportunity for more short-term relationships with patients. As a per diem visiting nurse, I may walk into a home for a brief interaction with a patient who I may never see again. With no history, no biases, and no preconceived notions, that moment is wide open for creative and compassionate interaction. As a per diem nurse in a small residential hospice, I may come to work one day and have a deeply emotional connection with a patient, only to return the following week to learn that that person has died. Thus, while a long-term investment is not an option in these relationships, it presents a golden opportunity to make each interaction count, holding nothing back and letting that moment be all that it can be.

While I am grieving the loss of many of the connections which I have nurtured over the years, I am simultaneously celebrating the relief that I feel as I relinquish the enormous responsibility that those long-terms relationships have brought to bear. Human interaction allows for depth and intimacy in many ways, and I plan to use my interpersonal skills in such a manner as to continue to satisfy my need for emotional intimacy with patients, even if those relationships are short-lived.

In this moment, as I write this missive, I feel a pain in my heart as the faces of patients I love pass over my mental movie screen. As I release my guilt and sense of responsibility, I shower each individual with compassion and understanding for their suffering, and wishes for healing and satisfaction with their lives, their health, and the relationships which they have with their medical providers. Even if I am no longer present in their daily lives, what we have shared is something which cannot be erased, and the value of those interactions---and the emotional and spiritual reverberations therein---can still be carried in our hearts.

Running for My Money

Today was one of those days where this line of work can give an earnest Nurse Care Manager a run for his money. (And I do certainly feel like I'm running for my money today.)

First, there's the patient with acute psychosis who apparently went on an inhaled heroin binge this weekend to celebrate finishing a very important multiple-month medical treatment. She told me that a friend had suggested going out to a fancy dinner instead of blowing her money on heroin. "It was actually a pretty good idea," she said with a laugh. After discussing the voices in her head and her non-compliance with taking her medications, she agreed to go by ambulance to the ER for an evaluation.

Another patient just seems to be having a hard time getting his life on track (a familiar complaint and observation here at "Train Wrecks 'r' Us". I feel deep compassion for his suffering, but sometimes it seems we just have to sit and let them work it out themselves.

The next patient complains about my long leave-of-absence, and says over the phone, "You mean, you've been back since yesterday and you haven't called me yet? I missed you so much!" How will I break the news to her that, in five weeks, I'll be permanently gone from her life?

Still another patient hears the news of my imminent departure and says, "Oh no! Another doctor leaving me behind? What next?" (She always refers to me as her doctor.)

These and other reactions are enough to make me feel guilty for leaving, but then I simply remind myself of the reasons why I'm leaving, the multiple stressors, the fast pace, the overwhelming feeling that I am running a race with no end in sight. I've been running like this for seven years, and working full-time for eleven.

We all run for our money in many ways, and any line of work will generally keep one running. This particular line has simply worn out the treads of my old Nurse Care Manager tires. I'm just due for a tune-up, some new treads, and a new place to run. In old-fashioned terminology, I'm "plum worn out" and have opened myself up to a new way to make my living in the world. The hardest part of that process is saying goodbye, and that is without a doubt par for the course.

Hello and Goodbye

I returned to work today following my six-week leave of absence, and while it was nice to say hello to friends, colleagues and patients once again, the reality is that I also have to begin saying goodbye as soon as I say hello. With my exit (stage left) planned for January 18th, time is of the essence to begin the disengagement process. It's an interesting exercise, and long-disused emotional muscles are being flexed as we speak. And when new muscles are flexed, we all know there's some growing pains.

It's easier than I thought to get started. I have to try to say goodbye to more than 80 patients, many of whom I have worked with for seven years, sharing numerous ups and downs and the challenges of poverty and chronic illness. Having begun, saying goodbye is not as difficult as I imagined. Then again, I have yet to speak with the patients with whom I have shared the most closeness and emotional intimacy. That is where the emotional rubber meets the road.

I was on the phone with one particular patient today. I told her I would be leaving the practice on January 18th. She seemed to take it in stride, said she loved me and would miss me, and agreed to get together next week for what would probably be our final visit. Another patient simply said, "Why are you leaving? Is it for more money?". Well, not exactly. Just more time at home.

One of my favorite patients, a vulnerable twenty-three year old young woman---a year younger than my son---was the most wrenching goodbye to date. When I broke the news to her over the phone today, I felt myself wince, and I could hear the strain in her voice. We agreed to meet at her home on Wednesday to check in. That therapeutic relationship will be one of the most difficult to terminate. That is the first small pain of this process.

So, five weeks of goodbyes, explanations, the transfer of crucial information, and the formulation of a new work life. An interesting way to end a year-----and to start anew.

Therapeutic Relationships: How (and When) to Say Goodbye?

What do clinical boundaries really mean? Where does a therapeutic relationship end and a friendship begin? When we interact on deep and profound levels with clients/patients over long periods of time---sometimes for years---what does it mean to say goodbye? Is it possible to satisfactorily take one's leave of a long-term therapeutic relationship and feel OK saying "Have a nice life!" as the door slams on your way out

Having just emerged from a psychotherapy appointment wherein I was discussing just these issues, my mind and heart are simply brimming with thoughts and feelings about just such scenarios.

Leaving a job is (almost always) a process of letting go, of relinquishing the past in the interest of a newly forged potential future. When one leaves a workplace, there are the inevitable goodbyes to colleagues, "subordinates", "superiors", and others with whom one shared a relatively large portion of one's waking life. This is no small matter, and such a leave-taking is more often than not fraught with uncertainty, nostalgia, and a tinge of regret. It is an accepted and normal phenomenon that, when one gives notice and begins to prepare to leave a workplace, that workplace will suddenly seem more friendly, more amenable, and more comfortable. It's almost as if the Universe begins immediately to test one's resolve to leave just as one submits one's resignation. How maddening!

For myself, being on a leave of absence has allowed me more than sufficient time to process my decision to leave, and I have already begun the process of considering my patients and colleagues and what those goodbyes will entail. In a recent post, I began to delineate those challenges. As for colleagues, maintaining contact is simple. Phone calls, emails, dinner or lunch invitations, the occasional party or professional gathering---those relationships can be maintained like any acquaintance or friendship. Inevitably, time and lack of frequent proximity will preclude frequent contact, with many of those professional but collegial relationships falling by the wayside over time, some more quickly than others.

Now, when it comes to patients, that is another arena entirely, and a great deal of forethought must be given to a decision to offer to maintain contact following the end of a therapeutic relationship. Of my 80 patients, there are probably thirty with whom I feel a deep affinity and positive mutual regard, so much so that ending those relationships will be emotionally difficult. Amidst that group of thirty there are probably ten people to who I feel an even deeper connection, and saying permanently goodbye would be painful. Narrowing the field further still, there are most likely two or three people with whom I feel an intimate, almost familial bond, and these are the therapeutic relationships which I could foresee morphing into friendships, albeit friendships with strict parameters and severely limited scope.

Considering such an outcome, one must ask certain questions:

-Does the client want continued connection?

-Is the offer of a continuing friendship/connection in the patient's best interest?

-Are you pursuing this friendship out of guilt or true desire for such?

-How will the new boundaries of such a relationship be established?
-How would said individual contact you?
-Will expectations of frequency of contact be considered?
-Why not just say goodbye?

There are dozens of questions to consider, many of which perhaps you, esteemed Reader, could raise (and please do!). This is a conversation worth having!

Those of us in Human Services and the so-called "helping professions" constantly face the issues of boundaries, transference, counter-transference, and projection. When facing the end of a therapeutic alliance, all bets are off and the game becomes simultaneously murkier and much simpler. The path of least resistance? Say "goodbye, nice to know you, have a good life, and thanks for being you". The path of potential complication (but also of richness and authenticity)? "Let's stay in touch and see what our new relationship/friendship is capable of within certain parameters". In all likelihood, most connections made in this way will, like tangential friendships, fizzle out over time. People move, phone numbers change, lives develop through unanticipated twists and turns, address books are lost, and the frequency of contact gradually subsides. Still, the effort was made, and true authenticity was honored.

As Jerome Groopman, M.D. writes so eloquently in his outstanding book, The Anatomy of Hope (and please simply subsitute the word "nurse" for "doctor" as you read):

"There are some patients whom a doctor grows to love. It is a unique type of love, distinct from any other type of love the doctor has experienced before. It moves outside the bounds of the usual doctor-patient relationship; feelings and thoughts are no longer strictly professional and are shared among true friends."

If this area is simultaneously murky and simple, I am certainly still in the murk. And, as I do in many areas of life when I am faced with difficult choices, I remember that age-old adage that I have quoted here on Digital Doorway before: "Don't just do something, sit there." Thus I will sit with these feelings, with this sense of impending and inevitable change, and perhaps, if I am quiet enough, the answer will make itself known.

Attachment, Anticipatory Grief, and Goodbyes

Faced with returning to my full-time job in mid-December following my six-week medical leave-of-absence, it has become painfully apparent to me that my days there are numbered. With the prospect of a job-share having fallen through, I face a slew of choices vis-a-vis my employment status, and the possibilities, while exciting in their potential, also open up tender emotional areas of attachment and anticipatory grief.

Having worked in my current position for seven years, a great deal of my identity as a nurse has revolved around serving low-income, inner-city populations whose vulnerability to disease and psychosocial dysfunction makes them ripe for our services. An endless well of need and dependence, my group of 80 patients have lived in my brain and heart for all of these years, and my emotional closeness with a number of them makes it most difficult to consider leaving my position for new horizons.

I have practiced nursing in a manner in which "therapeutic use of self" is a frequent technique of connection and teaching, using examples from my own life and struggles with chronic illness and depression as teaching tools and methods of expressing sincere empathy. Such disclosure, as well as my very personalized approach to nursing practice and therapeutic relationships in general, engenders an emotional intimacy that is slightly outside the norm for medical and nursing practice. For this reason, I have become quite invested in the lives and well-being of some of my patients, and I fully realize that this is a potential factor in the eventual development of burnout and compassion fatigue over time. I recently wrote a blog entry about vicarious traumatization, a phenomenon which is more than theory for me. It appears that my patients' trauma and traumatic histories have also begun to trigger my own personal trauma history, further exacerbating my feelings of burnout and compassion fatigue.

With time on my hands during this leave of absence, I have had opportunity to reflect on my relationships with a number of patients, and the notion of saying goodbye and terminating said relationships brings me great pain. As I conjure a mental image of this patient or that patient, I experience a wincing sensation wherein I think, "Oh, no! How will I say goodbye to him/her?" And the thought of each patient of whom I am fond evinces yet another uncomfortable sensation of loss.

This workplace where I have given my all for seven years is like no other I have experienced. United in our mission to serve the poorest, sickest, and most dysfunctional sub-populations, we are also united in a day-to-day feeling of being overwhelmed, of swimming against a steady current of unquenchable need, and of knowing that our collective and individual levels of stress are potentially hazardous. As much as we complain about our patients and their neediness, there must also be an aspect of attachment and addiction to such drama on our parts as well. There must be some secondary gain for us as we slog through the challenges of our days, striving to keep our heads above water in a current which changes directions---and depth---without notice or sympathy for our collective and individual plight. The undercurrent of family and camaraderie under duress keeps us afloat, even on the worst of days.

Within the adjacent inner-city community health center with which we partner to care for our patients---and where our patients receive their primary healthcare---there is a team of doctors with the majority of whom I have developed stellar working relationships. These doctors, all of them very committed to the care of the disenfranchised, poor, and chronically ill, have consistently treated me with a level of respect and professionalism unparalleled in my experience as a nurse. This sentiment is echoed by most of my nurse colleagues, and the learning and teaching which these working relationships engender is priceless. On a first-name basis since the beginning, my opinions and suggestions are taken seriously by these docs, and our discussions are never one-way---rather, there is an exchange of ideas focused on the ultimate goal of improved health and function for our mutual patients, although I frequently do feel that I am left with more responsibility than I can handle. Still, I see that my efforts are recognized and appreciated, and that my opinion is thoroughly and thoughtfully considered. If I am mistaken, it is always pointed out in a gentle and kind way with a goal of teaching and learning which is free from games of power and hierarchy, with few exceptions.

So why leave, you may ask? Why walk away from a situation in which satisfying professional relationships, clinical skill development, and challenging medical and psychosocial situations stimulate my mind, spirit and soul? It is because this level of engagement and deep involvement with extremely needy and often dysfunctional patients over a long period of time has whittled away at my core, slowly but surely damaging my ability to enjoy life outside of my work, causing such levels of stress that my personal quality of life has become diminished. Whether directly related to this job or simply a matter of synchronicity and coexistence , my own constellation of chronic illness, chronic pain, and long-term struggles with major depression are necessitating a change of lifestyle, a ratcheting down of the intensity I experience vis-a-vis my professional life. Perhaps I understand and empathize with my patients so well because of my own chronic illnesses, but because of those personal issues, that empathy, while helpful and useful therapeutically for my patients, is slowly but surely eroding my own ability for healing.

Drawing on my interest in Buddhism, I realize that these sensations and feelings, while sincere and quite real, are a manifestation of attachment. Various attachments arise in relation to possessions, people, relationships, circumstances, and even feelings and sensations. My reluctance to leave my workplace after seven years is, to a large extent, a reflection of a certain level of comfort I have developed, even though that comfort paradoxically coexists with burnout, overwork, and a growing sense of frustration with the intensity of the work and the programmatic dysfunctions of our organization. How to reconcile all of these factors and stay on the same path without incurring further personal damage?

I am at a turning point in my career. There are new avenues of nursing and my professional self which I long to explore, yet slogging away on the front lines of inner-city nursing practice---and the stressors therein---is most likely keeping me from pursuing those new avenues, my energy consistently sapped by the vicissitudes of the ol' 9 to 5.

So, I'll keep thinking, reflecting, meditating on it, and embrace these three more weeks of my leave of absence. Returning to work in mid-December, I fully expect at this point to return with my 30-day notice of resignation in hand. Sad, true, difficult, painful, challenging........necessary. And in the immortal words of Michelle Shocked, "the secret of a long life is knowing when it's time to go".